Cause of Device-Related Incident
*Not stated

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Clinical/Biomedical Engineering; Continuing Care; Nursing; Pediatrics

Device Factors
*Not stated

Document Type
Frequently Asked Questions (FAQ)

External Factors
*Not stated

Mechanism of Injury or Death
*Not stated

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
*Not stated

Beds [10-342]; Bedrails [10-341]

Preventing Patient Entrapment in Beds

FAQ [Health Devices Mar 1998;27(3):115-6]

Hospital: How can healthcare facilities minimize patient entrapment hazards associated with hospital beds?

ECRI: Patient entrapment has been reported to occur 1) between the bars of an individual siderail, 2) in the space between split siderails, 3) between the siderail and the mattress, or 4) between the mattress and the headboard or footboard. In August 1995, the U.S. Food and Drug Administration (FDA) issued a Safety Alert(1) that provided recommendations to minimize the entrapment risk. At FDA's request, ECRI reviewed a draft of that Alert and commented extensively before it was published. The recommendations of FDA and ECRI are summarized as follows:

  1. Inspect all hospital bed frames, siderails, and mattresses as part of a regular maintenance program to identify possible areas of entrapment. The alignment of those components should be such that no gap is wide enough to entrap a patient's head or body. Be aware that gaps can be created by movement or compression of the mattress caused by weight, patient movement, or bed position.
  2. Not all siderails, mattresses, and bed frames are interchangeable. If you have, or plan to purchase, siderails or mattresses other than those specified by the bed manufacturer, be sure they are compatible with your existing beds.
  3. Ensure that all siderails are installed according to manufacturer instructions.
  4. Consider implementing additional safety procedures (e.g., protective barriers to close off open spaces) for patients at particular risk for entrapment (e.g., elderly patients, patients with altered mental status or general restlessness).
  5. Siderails are not restraints; do not use or rely on siderails to confine or restrain a patient.


  1. U.S. Department of Health and Human Services. FDA safety alert: Entrapment hazards with hospital bed side rails [letter]. 1995 Aug 23.


  • Beds [10-342]
  • Bedrails [10-341]

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